ORIGINAL ARTICLE

Influence of temporomandibular joint disc

displacement on craniocervical posture
and hyoid bone position
Jung-Sub An,a Da-Mi Jeon,a Woo-Sun Jung,b Il-Hyung Yang,c Won Hee Lim,d and Sug-Joon Ahne
Seoul, Korea

Introduction: The purpose of this study was to evaluate craniocervical posture and hyoid bone position in or-
thodontic patients with temporomandibular joint (TMJ) disc displacement. Methods: The subjects consisted of 170
female orthodontic patients who consented to bilateral magnetic resonance imaging of their TMJs. They were
divided into 3 groups based on the results of magnetic resonance imaging of their TMJs: bilateral normal disc
position, bilateral disc displacement with reduction, and bilateral disc displacement without reduc-tion. Twenty-five
variables from lateral cephalograms were analyzed with 1-way analysis of variance to investigate differences in
craniocervical posture and hyoid bone position with respect to TMJ disc displacement status. Pearson correlation
coefficients were calculated to analyze the relationships between craniofacial morphology and craniocervical
posture or hyoid bone position. Results: Subjects with TMJ disc displacement were more likely to have an
extended craniocervical posture with Class II hyperdivergent patterns. The most significant differences were found
between patients with bilateral normal disc position and bilateral disc displacement without reduction. However,
hyoid bone position in relation to craniofacial references was not significantly different among the TMJ disc
displacement groups, except for variables related to the mandible. Pearson correlation coefficients indicated that
extended craniocervical posture was significantly correlated with backward positioning and clockwise rotation of
the mandible. Conclusions: This suggests that craniocer-vical posture is significantly influenced by TMJ disc
displacement, which may be associated with hyperdivergent skeletal patterns with a retrognathic mandible. (Am J
Orthod Dentofacial Orthop 2015;147:72-9)

D isc displacement of the temporomandibular joint

1
(TMJ)
Various imaging techniques are available for evalua-
tion of the TMJ, such as transcranial radiography,
arthrography, tomography, computed tomography, and
is a common temporomandibular disorder (TMD) and refers to 5
magnetic resonance imaging (MRI). Among them, MRI
an abnormal positional rela-tionship between the articular disc
2 is the only modality that directly depicts the disc and is
and the condyle, fossa, and articular eminence. TMJ disc
the gold standard in determining articular disc po-sition
displacement generally progresses from a reducing to a
nonreducing state and may lead to TMJ clicking, crepitus, and in relative to the condyle and articular eminence because of
6
2-4
some cases, pain and jaw movement limitations. Common its high diagnostic accuracy. In addition, it also offers
causes of TMJ disc displacement include trauma and other advantages, such as noninvasiveness, lack of soft
4 tissue distortion, minimal pain, minimal risk potential,
parafunctional habits, such as clenching and bruxism.
7
and lack of ionizing radiation exposure. Approximately
From the Dental Research Institute and Department of Orthodontics, School of 30% of asymptomatic adults and 82% of symptomatic
Dentistry, Seoul National University, Seoul, Korea.
a patients have some form of TMJ disc displacement, as
Postgraduate student.
b 6
c
Researcher. determined by MRI.
Assistant professor.
d
Associate professor.
Previous studies have investigated the relationship
e
Professor. between TMJ disc displacement and dentofacial
All authors have completed and submitted the ICMJE Form for Disclosure of charac-teristics in orthodontic patients, reporting that
Potential Conflicts of Interest, and none were reported. patients with TMJ disc displacement have decreased
Address correspondence to: Sug-Joon Ahn, Dental Research Institute and
Department of Orthodontics, School of Dentistry, Seoul National University,
posterior facial height as well as backward positioning
8,9
101 Deahak-ro, Jongno-Gu, Seoul 110-768, Korea; e-mail, titoo@snu.ac.kr. and clock-wise rotation of the mandible. Since
Submitted, April 2014; revised and accepted, September 2014.
craniocervical posture and hyoid bone position can be
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists. associated with dentofacial morphology, both of these
http://dx.doi.org/10.1016/j.ajodo.2014.09.015 features could be significantly influenced by TMJ disc
72
An et al
10,11
displacement. However, the associations between
TMJ disc displacement and craniocervical posture or
hyoid bone position have not yet been fully
investigated. Although the effects of TMD on
craniocervical posture and hyoid bone position have
been investigated, the results remain controversial.
Several studies have reported an association between
12-16
TMD and craniocervical posture, but others do not
support the connection between TMD and
17-20
craniocervical posture or hyoid bone position. The
purpose of this study was to investigate the
relationships between TMJ disc displacement and
craniocervical posture, and between TMJ disc
displacement and hyoid bone position, using MRI. The
null hypothesis was that no significant relationships
would be found between TMJ disc displacement and
craniocervical posture, or between TMJ disc
displacement and hyoid bone position.
MATERIAL AND METHODS
Female subjects were recruited from patients who
consented to bilateral MRI of their TMJs. All subjects had
a primary complaint of malocclusion, and routine lateral
cephalograms were taken in natural head position with an
Asahi CX-90SP II (Asahi Roentgen, Kyoto, Japan).
Natural head position was determined by having the sub-
21
jects look straight into a mirror in a standing position. A
chain plumb line was suspended in front of the cassette to
indicate a true vertical line. The MRI images were taken
to evaluate TMJ status mainly because of TMJ symptoms
including TMJ sounds, pain, masticatory muscle tender-
ness, limited mandibular movement, and locking. Exclu-
sion criteria were (1) age less than 17 years, (2) any
systemic disease, (3) history of orthodontic treatment,
(4) history of facial cosmetic or orthognathic surgery,
(5) history of trauma involving the TMJ, (6) juvenile rheu-
matoid arthritis, (7) history of TMJ treatment, (8) airway
obstruction, (9) oral habits, (10) TMJ disc displacement
of a greater severity on the unilateral side, and (11) partial
TMJ disc displacement or TMJ disc displacement with
partial reduction. This research protocol was approved by
the institutional review board of the Seoul National
University Dental Hospital (CRI11040).
Radiologists with MRI experience with the TMJ
inter-preted the images blinded to the clinical
information. According to disc position, TMJ disc
status was divided into 3 categories as follows.
1 Normal disc position. In the closed-mouth position, the
intermediate zone of the disc was interposed between the
condyle and the posterior slope of the articular eminence,
with the anterior and posterior bands equally spaced on either
side of the condylar load point.
American Journal of Orthodontics and Dentofacial Orthopedics
73
2 Disc displacement with reduction. The disc was
ante-riorly displaced relative to the posterior slope of
the articular eminence and the head of the condyle in
the closed-mouth position, but the disc was reduced on
mouth opening.
3 Disc displacement without reduction. The disc was
anteriorly displaced relative to the posterior slope of
the articular eminence and the head of the condyle, and
the disc was not reduced on mouth opening.
The position and shape of the articular disc of the TMJ
were carefully evaluated according to the classifica-tion
criteria. We excluded patients with a unilaterally different
disc displacement status because the possible skeletal
morphologies associated with unilateral disc displacement
would be obscured by averaging of the right and left
landmarks used to determine their loca-tion, and
unilaterally different disc displacement status may
asymmetrically influence craniocervical posture or hyoid
bone position, which is difficult to measure in lateral
22
cephalometric analysis. From the originally selected
patients, only those with bilateral normal disc status (BN),
bilateral disc displacement with reduction (DDR), and
bilateral disc displacement without reduction (DDNR)
were included in this study.
One investigator (S-J.A.), who was blinded to the
clinical information and the disc position, traced all
lateral cephalograms. Eighteen landmarks were
recorded on each radiograph using a digitizer with a
desktop computer, and 25 variables were calculated
from these landmarks: 9 variables for craniocervical
posture, 7 for hyoid bone position, and 9 for
craniofacial morphology (4 for vertical and 5 for
sagittal craniofacial morphologies). The positions and
definitions of the landmarks are shown in Figure 1, and
the locations of the reference planes are shown in
Figure 2. Measure-ments for craniocervical posture,
hyoid bone position, and craniofacial morphology are
shown in Figures 3, 4, and 5, respectively.
Lateral cephalograms of 20 randomly selected sub-
jects were measured again to test the magnitude of mea-
surement errors. The intraclass correlation coefficients for
the reliability of tracing, landmark identification, and
analytic measurements were greater than 0.98.
Descriptive statistics were calculated for all vari-ables.
The differences in the cephalometric variables for
craniocervical posture, hyoid bone position, and
craniofacial morphology with respect to the TMJ disc
displacement status (BN, DDR, and DDNR) were tested
with 1-way analysis of variance. Scheffe multiple com-
parisons were performed at a significance level of 0.05 to
analyze between-group relationships. To investigate
January 2015 Vol 147 Issue 1
74
Fig 1. Landmarks used in this study: 1, nasion; 2, sella; 3,
orbitale; 4, porion; 5, basion; 6, anterior nasal spine; 7,
posterior nasal spine; 8, Point A; 9, Point B; 10, pogonion;
11, menton; 12, gonion; 13, RGn (most protrusive point of
retrognathion); 14, hyoidale (Hy, most superior and ante-
rior point on the body of the hyoid bone); 15, cv2tg
(tangent point of the superoposterior extremity of the sec-
ond cervical vertebra); 16, cv2ip (most posteroinferior point
on the second cervical vertebra); 17, cv3ia (most an-
teroinferior point on the third cervical vertebra); 18, cv4ip
(most posteroinferior point on the fourth cervical vertebra).
the correlations between craniofacial morphology and
craniocervical posture or hyoid bone position, Pearson
correlation coefficients were calculated.
RESULTS
A total of 170 female subjects were included in this
study (Table I). Their age range was 17.0 to 50.8 years
(mean age, 24.5 6 5.7 years). There were no significant
differences in age distribution among the 3 study
groups (data not shown).
Table II presents the differences in craniocervical
posture, hyoid bone position, and craniofacial
morphology with respect to TMJ disc displacement sta-
tus (BN, DDR, and DDNR). Significant differences were
found in craniocervical posture between the BN and
DDNR groups (Table II). Subjects with DDNR had larger
angles between the craniofacial reference planes and the
cervical vertebrae (FH/CVT, NL/CVT, FH/OPT, and NL/
OPT) than did the subjects with BN, indicating that sub-
jects with DDNR had extended craniocervical posture
compared with those with BN. Although the subjects
January 2015 Vol 147 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
An et al
Fig 2. Craniocervical reference planes used in this study:
1, nasion-sella line (NSL, plane through nasion and sella);
2, true horizontal plane (HOR, true horizontal plane pass-
ing through sella); 3, Frankfort horizontal plane (FH, plane
through porion and orbitale); 4, nasal line (NL, line through
the posterior nasal spine and anterior nasal spine); 5,
mandibular plane (MP, line through gonion and menton); 6,
cervical vertebrae tangent (CVT, line through cv2tg and
cv4ip); 7, odontoid process tangent (OPT, line through
cv2tg and cv2ip).
with DDR demonstrated intermediate values, there was
no significant difference in craniocervical posture be-
tween the BN and DDR groups, or between the DDR and
DDNR groups. Angles between the cervical vertebrae and
the true horizontal plane (HOR/CVT and HOR/OPT) or
the mandibular plane (MP/CVT and MP/OPT) were not
significantly different among the 3 groups. Cervical
curvature (OPT/CVT) also did not vary significantly
among the different TMJ disc displacement groups.
Among the variables for hyoid bone position, only
measurements related to the mandible were significantly
influenced by TMJ disc displacement status. Subjects with
DDNR had a decreased hyoid angle (Go/Hy/Me)
compared with those with BN or DDR (BN 5 DDR .
DDNR). In addition, the hyoidale to the most pro-trusive
point of retrognathion distance (Hy-RGn) decreased as
TMJ disc displacement status increased in severity from
BN to DDNR (BN .DDR .DDNR). However, distances
between craniocervical landmarks or reference planes and
the hyoid bone (Hy-Ba, Hy to NSL, Hy to NL, Hy-cv3ia,
and Hy to cv3ia-RGn) did not show significant
differences according to TMJ disc displacement status
(Table II).
An et al
Fig 3. Variables of craniocervical posture (all are angular
measurements): 1, true horizontal plane to cervical verte-
brae tangent angle (HOR/CVT); 2, Frankfort horizontal
plane to cervical vertebrae tangent angle (FH/CVT); 3,
nasal line to cervical vertebrae tangent angle (NL/CVT); 4,
mandibular plane to cervical vertebrae tangent angle
(MP/CVT); 5, true horizontal plane to odontoid process
tangent angle (HOR/OPT); 6, Frankfort horizontal plane to
odontoid process tangent angle (FH/OPT); 7, nasal line to
odontoid process tangent angle (NL/OPT); 8, mandibular
plane to odontoid process tangent angle (MP/OPT); 9, the
cervical curvature, downward-opening angle between
odontoid process tangent and cervical vertebrae tangent
(OPT/CVT, positive when the cv4ip is located on the left
side of odontoid process tangent).
As previously reported, subjects with TMJ disc
displacement have a retrognathic mandible with a hy-
8,9
perdivergent skeletal pattern (Table II). Our study
showed that increased ANB, and decreased SNB and N
perpendicular to pogonion (PNP), are specific sagittal
craniofacial morphologies in subjects with TMJ disc
displacement. In addition, these skeletal characteristics
became more severe as TMJ disc displacement progressed
from BN to DDNR. However, variables representing
maxillary position (SNA and N perpendicular to point A
[ANP]) were not significantly different among the 3
groups. Subjects with DDNR had a hyperdivergent
skeletal pattern: eg, increased Frankfort-mandibular plane
angle (FMA), decreased posterior facial height (PFH),
and decreased facial height ratio (FHR) compared with
those with BN or DDR. In contrast to sagittal craniofacial
morphology, vertical craniofacial morphology did not
vary significantly be-tween the BN and DDR groups
(Table II).
Correlations between craniofacial morphology and
craniocervical posture or hyoid bone position are
American Journal of Orthodontics and Dentofacial Orthopedics
75
Fig 4. Variables of the hyoid bone position (all are linear
measurements except for Go/Hy/Me): 1, linear distance
between the hyoidale and basion (Hy-Ba); 2, perpendic-
ular distance between the hyoidale to nasion-sella line (Hy
to NSL); 3, perpendicular distance between the hyoi-dale
to nasal line (Hy to NL); 4, linear distance between the
hyoidale and RGn (Hy-RGn); 5, linear distance be-tween
the hyoidale and cv3ia (Hy-cv3ia); 6, perpendicular
distance between the hyoidale and cv3ia-RGn plane (Hy to
cv3ia-RGn, positive when the Hy is located below the
cv3ip-RGn plane); 7, hyoid angle, angle of Go-Hy-Me
(Go/Hy/Me, the angle is larger when the hyoidale is
located above the mandibular plane).
presented in Table III. Generally, craniocervical posture
(FH/CVT, NL/CVT, FH/OPT, and NL/OPT) was signifi-
cantly correlated with variables representing sagittal
(ANB, SNB, and PNP) and vertical (FMA and FHR)
craniofacial morphologies, and subjects with extended
craniocervical posture had a retrognathic mandible with a
hyperdivergent skeletal pattern. However, cervical
curvature (OPT/CVT) was not significantly correlated
with craniofacial morphology.
The hyoid angle (Go/Hy/Me) and the distance be-
tween the hyoidale and the most protrusive point of ret-
rognathion (Hy-RGn) were significantly correlated with
craniofacial morphologic variables (Table III). Both
values decreased as the skeletal pattern became more hy-
perdivergent (increased FMA and decreased FHR) and as
the mandible was located more posteriorly (increased
ANB and decreased SNB and PNP).
DISCUSSION
The relationships between TMJ status and craniocer-
vical posture have not been fully addressed, specifically in
orthodontic patients. This may be due to the
January 2015 Vol 147 Issue 1
76 An et al

DDNR had increased FH/CVT, NL/CVT, FH/OPT, and

Fig 5. Variables of craniofacial morphology: 1, Frankfort
horizontal plane to mandibular plane angle (FMA); 2,
anterior facial height (AFH, linear distance between na-
sion and menton); 3, posterior facial height (PFH, linear
distance between sella and gonion); 4, ANB angle; 5,
SNA angle; 6, SNB angle; 7, N perpendicular to Point A
(ANP); 8, N perpendicular to pogonion (PNP); 9, facial
height ratio (FHR, ratio of posterior facial height [3] to
anterior facial height [2]).
Table I. Number and age distribution of subjects with
BN, DDR, and DDNR
Group BN DDR DDNR
Subjects, n (%) 53 (31.2) 55 (32.4) 62 (36.5) 170 (100)
Age (y)
Mean 23.7 6 6.6 25.1 6 5.4 24.6 6 5.3 24.5 6 5.7
Range 18.3-50.8 17.3-42.0 17.0-41.0 17.0-50.8
methodologic problems of previous studies, such as
inadequate sample sizes and subjective criteria for clas-
12,13,17,18,23
sifying TMJ status. In this study, we used a
large sample size (170 subjects) including a control
group (BN TMJs). In addition, the subjects were
objectively classified with MRI of their TMJs, not with
subjective signs and symptoms. Furthermore, the
subjects were carefully controlled. Only subjects with
the same TMJ disc displacement conditions bilaterally
were included. Men were excluded to prevent skewing
the cephalometric measurements with sex-related dif-
ferences. To prevent growth-related size differences,
only female patients over the age of 17 years were
24
selected.
This study showed an association between TMJ disc
displacement and craniocervical posture. Subjects with
NL/OPT compared with those with BN (Table II).
Although there were no significant differences in the an-
gles between the BN and DDR groups, or between the
DDR and DDNR groups, there was a tendency toward
increased angles between the craniofacial reference
planes and the cervical vertebrae as TMJ disc displace-
ment progressed from BN to DDNR. This means that
head or cervical posture can change according to TMJ
disc displacement status. Since neither angle between the
cervical vertebrae and the true horizontal plane
(HOR/CVT and HOR/OPT) or the cervical curvature
(OPT/CVT) was significantly different among the 3 disc
displacement statuses, head posture may rotate above the
second vertebra without changes in cervical vertebral
position in relation to the true horizontal plane. Although
direct comparison was not possible, our find-ings are
similar to those of previous studies reporting that patients
with TMD have a more extended craniocer-vical posture
than the control group, without significant differences in
12
cervical curvature, and that there are no significant
differences in the curvature of the cervical vertebrae
between the third and seventh vertebrae after comparing
cervical vertebral alignment between sub-jects with TMD
19
and volunteers without TMD.
Despite changes in head posture, the positional rela-
tionships between the cervical vertebrae and the
mandibular plane (MP/CVT and MP/OPT) did not show
significant differences among the 3 TMJ groups. This
might be because mandibular position is significantly
associated with TMJ disc displacement status. Subjects
Total
with TMJ disc displacement generally had an increased
mandibular plane angle with extended craniocervical
posture (Table II). Because both cervical vertebrae and
the mandible are rotated clockwise in relation to the
craniofacial reference planes in subjects with TMJ disc
displacement, there may be no significant differences in
relationships between the cervical vertebrae and the
mandibular plane.
The association between TMJ disc displacement and
extended craniocervical posture can be explained in 2
ways. The first possibility is that extended craniocervical
posture may influence TMJ disc displacement. Previous
studies have reported that abnormal craniocervical
posture is an etiologic factor of TMD, postulating that as
the cranium rotates backward, the mandibular denti-tion
will be located more posteriorly in relation to the
maxillary dentition; in turn, the mandible will be
12,13
advanced to obtain occlusal support. Increased
muscular activity that develops as a result will lead to disc
12,13
displacement. Although the subjects with TMJ disc
displacement had a more extended craniocervical posture
in this study, they had a more posteriorly

January 2015 Vol 147 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
An et al 77

Table II. Comparisons of cephalometric variables among the BN, DDR, and DDNR groups
z
Variable BN DDR DDNR Significance Multiple comparisons
Craniocervical posture
HOR/CVT ( ) 98.7 6 6.9 99.5 65.8 99.6 65.9 NS
FH/CVT ( ) 96.6 6 8.2 98.3 66.3 100.3 67.1 * BN \DDNR
NL/CVT ( ) 96.1 6 8.7 98.3 66.4 99.6 66.9 * BN \DDNR
MP/CVT ( ) 67.3 6 8.8 67.6 67.0 64.7 68.5 NS
HOR/OPT ( ) 93.6 6 7.4 94.9 67.1 94.7 66.4 NS
FH/OPT ( ) 91.5 6 8.5 93.7 67.3 95.4 67.4 * BN \DDNR
NL/OPT ( ) 91.0 6 8.8 93.7 67.2 94.7 67.1 * BN \DDNR
MP/OPT ( ) 62.2 6 8.6 63.0 67.9 59.8 68.5 NS
OPT/CVT ( ) 5.1 6 2.8 4.6 62.9 4.9 62.5 NS
Hyoid bone position
Hy-Ba (mm) 76.3 6 5.6 77.0 66.0 75.1 66.1 NS
Hy to NSL (mm) 107.0 6 6.4 108.2 67.6 108.4 66.4 NS
Hy to NL (mm) 60.7 6 5.2 61.8 66.0 62.6 65.7 NS
Hy-RGn (mm) 38.4 6 5.7 35.5 65.5 32.3 65.5 y BN .DDR .DDNR
Hy-cv3ia (mm) 36.2 6 3.8 36.5 63.0 35.2 63.4 NS
Hy to cv3ia-RGn (mm) 1.5 6 6.1 0.0 65.0 0.5 65.9 NS
Go/Hy/Me ( ) 154.3 6 18.0 151.0 614.8 143.4 615.1 * BN 5 DDR .DDNR
Vertical craniofacial morphology
FMA( ) 28.9 6 7.0 30.6 66.7 35.5 67.0 y BN 5 DDR \DDNR
FHR (ratio) 0.63 6 0.06 0.62 60.05 0.59 60.06 y BN 5 DDR .DDNR
AFH (mm) 132.8 6 5.5 133.7 66.5 133.3 66.0 NS
PFH (mm) 83.7 6 7.6 82.6 66.6 77.9 66.7 y BN 5 DDR .DDNR
Sagittal craniofacial morphology
ANB( ) 2.4 6 4.5 5.1 62.4 7.7 62.8 y BN \DDR \DDNR
SNA( ) 81.1 6 3.1 81.6 63.2 81.4 62.8 NS
SNB( ) 78.7 6 4.9 76.5 62.9 73.8 63.6 y BN .DDR .DDNR
ANP (mm) 1.7 6 3.0 2.3 62.8 1.5 63.2 NS
y

PNP (mm) 1.32 6 10.43 6.32 66.65 14.05 67.73 BN .DDR .DDNR

NS, Not significant.

y z
*P \0.05; P \0.001; Scheffe multiple comparisons were used to analyze the intergroup difference at the level of a 5 0.05.
upper airway space with the same craniocervical
28
located mandible than did subjects with BN (Table II); posture. Therefore,
this differs from previous studies.
The second possibility is that TMJ disc displacement
may induce extended craniocervical posture. Previous
studies have reported that the severity of TMJ disc
displacement increases as the sagittal skeletal classifica-
tion changes from skeletal Class III to skeletal Class II,
and the vertical skeletal classification changes from hy-
8,9,25
podivergent to hyperdivergent. As a result, subjects
with skeletal Class II or hyperdivergent deformities have
a high possibility of severe TMJ disc displacement. In
addition, experimentally induced TMJ disc displacement
leads to significant impairment of vertical and horizontal
mandibular growth, and the amount of vertical or
horizontal skeletal change gradually increased as TMJ
disc displacement increased in severity in animal
26,27
studies. Because TMJ disc displacement frequently
occurs during puberty, it seems that TMJ disc
displacement can lead to a retrognathic mandible with a
hyperdivergent skeletal pattern; this in turn may reduce

extended craniocervical posture associated with TMJ disc
displacement may result from protective responses to
maintain upper airway space. This hypothesis is sup-
ported by our findings, indicating that extended cranio-
cervical posture is positively related to a hyperdivergent
and Class II skeletal pattern (Table III). de Farias Neto et
16
al also postulated that in the patients with TMD, altered
mobility of the articular disc limits the biome-chanics of
mouth opening and triggers compensatory extension of
the cervical vertebrae to prevent compres-sion of the
upper airway. However, the cause-and-effect relationships
American Journal of Orthodontics and Dentofacial Orthopedics
are not clear because the results were derived from cross-
sectional data.
Interestingly, TMJ disc displacement did not signifi-
cantly influence the positional relationships of the hyoid
bone to the craniofacial references and the cervical
vertebrae, but it significantly influenced the positional
relationships of the hyoid bone to the mandible (Go/
Hy/Me and Hy-RGn) (Table II). Subjects with TMJ disc
displacement, and specifically those with DDNR, had a
smaller hyoid angle (Go/Hy/Me) and a shorter hyoidale to
the most protrusive point of retrognathion distance
January 2015 Vol 147 Issue 1
78 An et al

Table III. Correlations between craniofacial morphology and craniocervical posture or hyoid bone position

Correlation

Variable FMA FHR AFH PFH ANB SNA SNB ANP PNP

Craniocervical posture

y y
HOR/CVT ( ) 0.241 NS 0.196* NS 0.240 0.169* 0.332y 0.153* 0.334y

y y y
FH/CVT ( ) 0.381 0.247y 0.270 NS 0.399 0.205y 0.499y 0.316y 0.591y

y y y
NL/CVT ( ) 0.256 0.192* 0.262 NS 0.315 0.248y 0.454y 0.193* 0.416y

y y
MP/CVT ( ) 0.547y 0.556 NS 0.512 NS NS NS NS NS

y y
HOR/OPT ( ) 0.258 0.154* 0.153* NS 0.242 0.168* 0.333y NS 0.325y

y y y
FH/OPT ( ) 0.396 0.256y 0.234 NS 0.399 0.207y 0.501y 0.290y 0.578y

y y y
NL/OPT ( ) 0.283 0.208y 0.231 NS 0.326 0.253y 0.467y 0.178* 0.422y

y y
MP/OPT ( ) 0.498y 0.519 NS 0.468 NS NS NS NS NS
OPT/CVT ( ) NS NS NS NS NS NS NS NS NS
Hyoid bone position
y y y
Hy-Ba (mm) NS 0.152* 0.247 0.281 0.162* 0.162* 0.257 NS 0.174*
y y y
Hy to NSL (mm) NS NS 0.341 0.289 NS 0.281 NS NS NS
y y y y
Hy to NL (mm) 0.237 NS 0.247 NS 0.236 NS 0.161* NS 0.267
y y y y y y
Hy-RGN (mm) 0.519 0.388 NS 0.396 0.584 NS 0.421 NS 0.562
y
Hy-cv3ia (mm) 0.181* 0.191* 0.165* 0.278 NS NS NS NS NS
Hy to cv3ia-RGn (mm) NS NS NS NS 0.174* NS NS NS NS

y y y y y y
Go/Hy/Me ( ) 0.385 0.358 0.168* 0.447 0.324 NS 0.339 0.151* 0.367
NS, Not significant.
y
*Pearson correlation is significant at the .05 level; Pearson correlation is significant at the .01 level.
in hyoid bone positions between subjects with and
19
(Hy-RGn) than did the subjects with BN, whereas the dis- without TMD. Other research regarding TMJ disc
tances between the hyoid bone and the craniofacial ref- displacement status with MRI also documented that the
erences (Hy-Ba, Hy to NSL, and Hy to NL) or the position of the hyoid bone was not significantly different
cervical vertebrae (Hy-cv3ia), and the relationship between subjects with a normal disc position and those
between the hyoid bone and the craniocervical reference 20
with disc displacement.
(Hy to cv3ia-RGn), were not significantly different among Generally, the facial profile is important in the diag-
the 3 TMJ disc displacement groups. The relationship be- nosis and treatment planning for orthodontic patients.
tween the hyoid bone and the mandible can be explained This study showed that TMJ disc displacement can
by the compensatory response of the hyoid bone to pre-
serve upper airway space. It seems that the position of the
hyoid bone may not significantly change during the
protective process, which maintains the pharyngeal
airway space and swallowing functions against back-ward
positioning and clockwise rotation of the mandible
associated with TMJ disc displacement. As a result, the
subjects with TMJ disc displacement have backward
positioning and clockwise rotation of the mandible with a
relatively stable hyoid bone position, which may change
the positional relationships of the hyoid bone to the
mandible significantly. This hypothesis is partly supported
by previous research that found no significant differences

influence craniocervical posture, although the cause-
and-effect relationship remains unclear. As a result, in
subjects with TMJ disc displacement, the retro-gnathic
profile is compromised by extending their
craniocervical posture despite the backward
positioning and rotation of the mandible. Recently, the
importance of the soft tissue paradigm has been
emphasized, and a normal soft tissue proportion is
considered a primary treatment goal in orthodontic or
surgical-orthodontic treatment.
29-31
Because
craniocervical posture is directly related to the soft
tissue profile of the face, this study suggests that
clinicians should carefully evaluate relationships
between the craniocervical posture and the facial
January 2015 Vol 147 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
profile in patients with potential TMJ disc
displacement before orthodontic treatment.
This study has the following limitations. The causal
relationships between TMJ disc displacement and cra-
niocervical posture, or between TMJ disc displacement
and the hyoid bone position, are not clear because our
results were derived from cross-sectional data. In
addition, these results are based on lateral cephalo-
grams with static posture; hence, they do not show the
function associated with mandibular kinetics. Further
studies with longitudinal data are needed to clarify the
relationships of intra-articular distance, mandibular
kinematics, and mandibular loading with
craniocervical posture. This would be helpful for the
diagnosis and treatment planning of patients with TMJ
disc displacement.
An et al
CONCLUSIONS
This study was performed to evaluate the relation-
ships between TMJ disc displacement and craniocervical
posture, and between TMJ disc displacement and hyoid
bone position, in adult orthodontic patients. The sub-jects
with TMJ disc displacement were more likely to have an
extended craniocervical posture with Class II hy-
perdivergent patterns. In contrast, hyoid bone position
was relatively stable irrespective of TMJ disc displace-
ment status. Therefore, the null hypothesis of our study
was partially rejected. Extended craniocervical posture
was significantly correlated with backward positioning
and clockwise rotation of the mandible. This study sug-
gests that craniocervical posture is significantly influ-
enced by TMJ disc displacement, which may be
associated with a hyperdivergent skeletal pattern with a
retrognathic mandible.
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American Journal of Orthodontics and Dentofacial Orthopedics January 2015 Vol 147 Issue 1